CAPACITY BUILDING SEMINAR AND PRACTICAL WORKSHOP SESSION TOPIC: Proactive Preventive Measures and Response on Emerging Infectious Diseases: A personal and Community Responsibility for Safety. (Case study- Ebola Virus Disease): A talk presented by: Nkemngo Francis N. M.Sc. Student- University of Buea, Cameroon 1 Active and servant member - Global Alliance for Tropical Health (GATH); Buea-Cameroon o Email:
[email protected]
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MAY 2018
OUTLINE OF PRESENTATION
PHASE I: LECTURE What is Ebola Disease Ebola Disease Transmission Ebola virus disease: Epidemiology Context: DRC & Cameroon Ebola virus disease: societal complex Monitoring and surveillance Outbreak Investigation Gaps and opportunities Public health response Preventive measures Ebola virus disease: Myths
PHASE II: PRACTICAL SESSION Hand washing practice Personal Protective Equipment usage (PPE)
RECOMMENDATION
TAKE-HOME MESSAGE
REFERENCES
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WHAT IS EBOLA DISEASE??
At first mention: oouuchh!!!! This Ebola again……
Re-emerging Infectious(*****) disease
Hemorrhagic fever; first occurred in Zaire (DRC)
Potential Bioterrorism agent= Global health threat
Species: 5 types Bundibugyo ebola virus Zaire ebola virus Sudan ebola virus Reston ebola virus Tai Forest ebola virus
What is an Ebola outbreak? A single confirmed Ebola case constitute a red alarm (“ outbreak”)
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PHASE I: LECTURE (EBOLA DISEASE)
Severe, fatal illness in humans caused by Ebola virus; considered a disease of jumping host. Viral strains= high rate of mutation= one of the world most infectious & deadly diseases with no cure (as of now)= creates a high level of fear
The highly pathogenic virus circulates undetected (as enzootic infections), until conditions change favoring their expression and recognition as severe human pathogens.
Once introduced= spread rapidly to the population due to highly levels of viraemia and virus shedding in body fluids (blood, saliva, urine, semen, breast milk, faeces, sweat):
Person-person transmission via blood, mucous membrane secretions, percutaeneous exposure (e.g. needle stick injury!!! Health workers) 4
EBOLA DISEASE: TRANSMISSION PATTERN
Health care workers are most at risk of being infected of the virus= administer treatment to patients suspected or confirmed of EVD without infection control precaution measures strictly respected.
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EBOLA DISEASE: RISK FACTORS FOR TRANSMISSION/1
West Africa: Bush meat consumption is an old tradition (linked to proper nutrition)
Multiple causes of increase EVD outbreaks= increased bush meat consumption; and transportation to previously inaccessible areas.
Inadequate hygiene and personal protective measures= considerable infection risk for healthcare workers
Cultural aspects: local funeral ceremonies with potential contact with body fluids from patients who have died from EVD= contribute to magnitude of outbreak. 6
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EBOLA DISEASE: RISK FACTORS FOR TRANSMISSION/2
Risk factors: primary and secondary.
Primary transmission RF: subsistence
activities involving hunting, gathering animal forest products and contact with wild animal presumed to be an Ebola reservoir.
Secondary transmission RF: contact with
patient febrile haemorrhagic syndrome (patient with high fever and bleeding from the nose, mouth or anus)
Established epidemiological chain of transmission
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EBOLA DISEASE: CLINICAL MANIFESTATIONS Evident clinical manifestation: Hemorrhagic fever; differentiate from other diseases presenting similar symptoms (malaria, typhoid, meningitis etc)
Initially: fever, headache, joint and muscle aches, sore throat, body weakness ,followed by diarrhea, vomiting blood, blood, a rash, red eyes, hiccups with internal and external bleeding in some cases o
Incubation period: 2 to 21 days 8
EBOLA VIRUS DISEASE: CASE DEFINITION/1 SUSPECTED CASE Fever (> 38.6C) AND Symptoms AND epidemiologic risk factors within past 21 days prior to symptom onset PROBABLE CASE Suspected case (Person Under Investigation-PUI) AND low risk exposure OR high risk exposure CONFIRMED CASE A case with laboratory- confirmed diagnostic evidence of Ebola virus infection
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EBOLA VIRUS DISEASE: CASES AND DEATHS Reporting Date
Total Cases (Suspected, Probable, and Confirmed)
Confirmed Cases
Total Deaths
Guinea
28 Dec 15
3,804
3,351
2,536
Sierra Leone
7 Feb 16
14,124
8,706
3,956
Liberia
14 Jan 16
10675
3160
4809
Italy
20 May 15
1
1
0
United Kingdom
29 Dec 14
1
1
0
Nigeria
15 Oct 14
20
19
8
Spain
27 Oct 14
1
1
0
Senegal
15 Oct 14
1
1
0
United States
24 Oct 14
4
4
1
Mali
23 Nov 14
8
7
6
28,639
15,251
11,316
TOTAL o
Ebola virus disease (DRC-2018): Not yet a PHEIC (WHO, 2018).
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DRC reported 39 suspected, probable or confirmed cases of Ebola between April 4 and May 13, including 20 deaths. 10
EPIDEMIOLOGY OF EBOLA VIRUS DISEASE/1
First discovered in Nzara (Sudan) and Yambuku- Zaire (today called DRC)
Since discovery more than three decades ago: natural maintenance cycle remains poorly defined?? A disease confined to the African race= African Governments must be responsible and prioritize their own health [ less prioritized by pharmaceutical companies, affects poor marginalized people, insufficient research funding] : Compare HIV/AIDS and Ebola research funding!!!!
Total of 26 outbreaks in Africa; 2018 Ebola outbreak in West Africa was linked to bush meat consumption
Further related Ebola cases reported: Nigeria, Senegal, Spain, USA, UK, Mali and France-Eastern Paris (A UN employee who contracted Ebola in Sierra Leone was being treated). 11
EPIDEMIOLOGY OF EBOLA VIRUS DISEASE/2
A disease of Global health
concern (not PH) with much impact in sub-Saharan Africa; disease of the poor.
Health emergency of
global alarm in poor vulnerable communities in Africa
Longest and largest= West
African outbreak (2014/2015); killed more than 11.313 people (WHO, 2015). 12
EBOLA VIRUS DISEASE: SOCIOECONOMIC IMPACT
Loss of lives; subdued growth rates
Aggravates poverty and food insecurity; destroys livelihood
Stigmatization of affected families; weakened social cohesion Political implications are also involved: poor management of the Ebola crisis by Governments has exposed citizens lack of trust in their governments.
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EBOLA DISEASE: RATIONALE FOR THIS TALK/1
EHF is an infectious disease with very high case-fatality rate for which vaccine is under experimentation.
From the chain of transmission of EVD in reported epidemics; such a transmission pattern is possible in communities that practice forest hunting and intense subsistence forest farming
Many of the animals found in forest are susceptible to infection by Ebola virus and may serve as reservoir for infection of humans
Also; many inhabitants of forested rural communities have poor knowledge and health seeking behaviors= contributory factors to risk exposure
To minimize the chances of an outbreak, knowledge on the prevention is very important.
Prevention can only be successful following an understanding of the risk factors 14 of exposure= which would be useful to develop educational messages targeting communities at risk.
EBOLA DISEASE: RATIONALE FOR THIS TALK/2
Although the disease has not been reported in Cameroon= The country stands at risk particularly as there are reports of serological evidence of Ebola virus infection
In addition: Ebola epidemics have been reported in neighboring countries to Cameroon (e.g. DRC)= cross boundary/territorial spread (POE)
Resources are needed to contain an Ebola outbreak= than to prevent it; prevention is mandatory in areas at risk.
The sensitization strategy in Cameroon for EVD is inadequate particularly at rural community level= often due to insufficient data.
This talk will potentially be contributory to the response of sensitization to this highly fatal disease= thus scaling up prevention strategies 15
CASE STUDY: DEMOCRATIC REPUBLIC OF CONGO (DRC)
Long standing history of civil war
Citizens are vulnerable to emerging & re-emerging infectious diseases
EVD outbreak declared last four years (26 August 2014) and this year (April 2018) in DRC= linked to bush meat consumption= Bat soup is a delicacy in this region .
Hunting and manipulation of fruit bats= high risk for primary transmission
Causative agent: Zaire Ebola virus (most virulent of all strains); case fatality ratio of ZEV infection was between 44% and 90%.
Continuous civil war and conflict; Absence of peace
Lack of community empowerment & involvement
Ebola Disease (DRC)
Weak & Ineffective leadership; Misuse of funds and resources
Collapsing Health System; poor communication System
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EBOLA VIRUS DISEASE(DRC): STATE-OF-THE ART KNOWLEDGE
Workers have recorded: 2 confirmed cases, 22 probable cases and 17 suspected cases of Ebola in three health zones of Congo’s Equateur province, and identified 432 people who may have had contact with the disease.
Outbreak was first spotted in the Bikoro zone, which has 31 of the cases and 274 contacts.
Also, 8 cases and 115 contacts noted in Iboko health zone.
The MOH (DRC) =worried about the disease reaching the city of Mbandaka with a population of about 1 million people, which would make the outbreak far harder to tackle
WHO RESPONSE: first batch of 4,000 experimental Ebola vaccines arrived in Congo’s capital Kinshasa
Vaccine, developed by Merck = sent from Europe by the World Health Organization (still not licensed but proved effective during limited trials in West Africa in the biggest ever outbreak of Ebola, which killed 11,300 people in Guinea, Liberia and Sierra Leone from 2014-2016).
1,500 sets of personal protective equipment sent;
An emergency sanitary kit sufficient for 10,000 people for three months have been put in place; 300 body bags sent for safe burials in affected communities
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PRESENT CONTEXT: CAMEROON SITUATION/1
Objectives of Ministry of Public Health (MoPH): Prevent disease and disabilities Promote health and wellbeing Prolong life
Quality health dissemination to population
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PRESENT CONTEXT: CAMEROON SITUATION/2
No detected/confirmed case of Ebola disease= MoPH
EVD has never been reported in Cameroon
Cases of suspected hemorrhagic fever: communiqué released by MoPH (health watch mechanism)
Depicts an active Monitoring and Surveillance team
MoPH (Cameroon):conscious, dynamic and trust-worthy
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PRESENT CONTEXT: CAMEROON SITUATION/3
Cameroon is labeled as a country at risk but with no reported case.
Studies in Cameroon have reported serological evidence of EBV in Cameron (Abs to Ebola virus among 1,517 apparently healthy persons in five regions of Cameroon)
Positive rate (9.7%) was found= confirming virus circulation in absence of clinical cases; highest rates(pygmies, young adults and rain forest farmers).
Studies have reported Ebola infection rate of 12.9% in Chimpanzees of Cameroon
Several Ebola epidemics have occurred in some West and Central African countries bordering Cameroon. 20
PRESENT CONTEXT: CAMEROON SITUATION/4
Equally, study reported seropositivity = Ebola among pygmies inhabiting the tropical forest of Central Africa, part of which is in Cameroon.
Cameroon chimpanzees might, therefore be survivors of an unknown local or regional epizootic.
Perhaps a less virulent member of the filovirus family is circulating in Cameroon, a situation that would account for the lack of local human cases and/or obseverd epizootics
It could also be that the less virulent Sudan strain of Ebola virus is circulating in Cameroon since Cameroon's rainforest is on the same latitude as southern Sudan where the less virulent strain has been circulating
Studies have been conducted to show that the southeastern equatorial rain forests harbors animals such as great apes and fruit bats susceptible to the EBV, with the fruit bat scientifically proven to be the main reservoir of the Ebola virus 21
PRESENT CONTEXT: CAMEROON SITUATION/5
Being that the S.E rainforest of Cameroon is part of the tropical rainforest, inhabitants of these areas including the Baka community are at high risk of exposure to the virus
The Baka community made up of the pygmies (majority) is one of the communities found in the East region of Cameroon with subsistence activities being hunting and farming.
The Bakas are hunter gatherer groups autochthonous or aboriginal to Central Africa
Hunting especially in the tropical rainforest is an activity that has been associated to a high risk of exposure to infection with the Ebola virus.
Thus their forest dwelling hunter gathering activities could expose them to the risk of Ebola virus and other zoonotic infections as they can easily get in contact with reservoirs
Cultural beliefs, behaviors, Knowledge Attitude and Practices also increases their risk of infection with Ebola virus. 22
EBOLA VIRUS DISEASE: “SOCIETAL COMPLEX”
Societal complex= conditioned with defined remote populations and influences spread of EVD. Include:
Civil war= Poverty= Poor healthcare= High birthrate (overpopulation)= Peripheral migration & Rural re-location= Underdevelopment= Climate change= Food insecurity Evidently; West African Ebola epidemic= demonstrated insufficiency in existing range of medical and epidemiological responses to emerging disease outbreaks. Particularly: post conflict contexts= with exceedingly poor healthcare infrastructures Rural Urban Cross boundary spread
Proactive community based responses= vital for containing Ebola disease 23
EBOLA DISEASE: MONITORING & SURVEILLANCE SCHEME
Preparedness and readiness against Ebola strive on strong preparedness measures at the national level and on specific preparedness measures such as surveillance, risk reduction, response and containment in a holistic and comprehensive manner Reduce anxiety by communicating technically correct messages to target population areas (i.e. public awareness) Mobilize communities to identify cases by communicating the importance to report suspicious cases rapidly Tight surveillance at PoE (airport, seaport, land borders etc)
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EBOLA DISEASE: INVESTIGATION OF AN OUTBREAK
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EBOLA DISEASE: CONTAINMENT LEVEL
BSL4 pathogen: requires maximum containment facility and barrier protection, particularly for health workers!!! Specimen transportation: Triple packaging system (diagram)
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EBOLA DISEASE: OUTBREAK RESPONSE PLAN/1
Good outbreak control relies on applying a package of interventions:
Activation and testing of emergency plans
Strengthening Case management capacities
Strengthening infection prevention and control capacities (safe burials, proper waste management, proper use of PPE, avoid contact with infected persons/animals)
Strengthening active surveillance and contact tracing
Strengthening Good laboratory diagnostic services 27
EBOLA DISEASE: OUTBREAK RESPONSE PLAN/2
Safe burials and social mobilization Enhancement of public information and social mobilization
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EBOLA VIRUS DISEASE: “GAPS & OPPORTUNITIES”
No drug; presently 4000 experimental vaccines
deployed to DRC (post-pharmacovigilance watch)!!
Currently exp’tal vaccines are tested for safety and effectiveness (DRC)
No licensed/FDA approved vaccines or drug yet = stimulus for scientific & healthcare research.
People who recover from Ebola infection develop antibodies= last for at least 10 years (vaccine feasibility)= Avenue to promote research
2018 Ebola outbreak provided Africa: tough lessons regarding the speed of R&D of protective medical countermeasures, ethical considerations of the use of experimental therapies in humans undercompassionate-use provisions, and the circumstances under which licenced drugs can be used off-label for treatment of other threat diseases. 29
EBOLA VIRUS DISEASE: “THE NEW DEAL”/1
Preventive measures: community engagement is key;
Raising awareness of risk factors for Ebola infection and protective measures that individuals can take is effective in reducing human transmission.
Risk reduction messages should focus on several factors:
Reducing the risk of wildlife-human transmission from contact with infected fruit bats or monkeys/apes and their raw meat consumption;
Animals must be handled with gloves and other appropriate protective clothing
Animal products (blood, meat) should be thoroughly cooked before consumption
Gloves and appropriate PPE equipment should be worn when taking care of ill30 patients in at home
EBOLA VIRUS DISEASE: “THE NEW DEAL”/2
Avoid contact with body fluids Regular hand washing with soap and water is required after visiting patients in hospital or at home.
Recommend sexual abstinence (3months) or condom usage during sex.
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EFFECTIVE INTEGRATION OF THE “ONE HEALTH” CONCEPT INTO CAPACITY BUILDING AND HEALTH POLICY IMPLEMENTATION “One Health” concept= vital in approach and feasibility
Concept is particularly relevant in the control of zoonoses, emerging & reemerging IDs and in combating antibiotic resistance
Promotes collaboration, team work and communication among various public health stakeholders: human health= animal (veterinary) health= environmental health (Eco-health)
Achieves better public health outcomes
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EBOLA DISEASE: PUBLIC HEALTH RESPONSE
Necessitates the collaboration of all actors & stakeholders: From Health to civil societies in grassroots communities.
Role of a sustainable health system (adequately trained health staffing, adequate facility coverage, isolation centers, screening travelers at PoE)
Primarily- vital role played by epidemiologist, public health experts (e.g. medical doctors, nurses, clinical biologist), microbiologist, health economist, health educators, community, YOU & I.
Application of the best medical and scientific knowledge available
Emergency funding from national and International health bodies, bilateral and multilateral humanitarian NGOs. 33
Essentially: “Prevention is better than cure”; if at all cure exist
PROACTIVE PREVENTIVE MEASURES/1 A).
Individual level
Proper hand washing= contact with blood Enveloped virus (Ebola) are susceptible to a broad range of detergents and disinfectants Diagram of proper hand washing Detergents: Destroys the lipid coat of the virus Prevents binding of viral spikes with receptors
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PROACTIVE PREVENTIVE MEASURES/2 B).
Community Level: A collective responsibility
Report any suspected case(Signs: bleeding gums, vomiting blood) to the nearest health facility for onward transmission and implementation of appropriate measures.
Deter the practice of keeping wake with corpse.
Mass Sensitization and Health Education of the target population on socio-cultural behavior & practices = negativities on health
Community empowerment and involvement
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MYTHS ON EBOLA DISEASE o o
Ebola virus was laboratory produced and introduced to Africa by the Whites: Reduce black population Exploit the resources of developing countries (Africa) Test their discoveries Ebola transmission is airborne Ebola virus disease can be transmitted by mosquitoes or other insects
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PHASE II: PRACTICAL WORKSHOP
Proper Hand washing: SOPs
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RECOMMENDATION
National- Regional-District-Local indaba to strengthen health systems and intensify fundamental/basic research.
Vital role of monitoring and surveillance mechanisms= effective mass media communication (Public health journalism).
Strong and effective leadership in the campaign for health for all
Mobilization and focused use of resources “With proper preparedness and readiness at country level, alongside proper awareness of the disease at community level, Ebola can easily be prevented and/or contained, and the consequential possible impact on health care systems, and the society at large be minimized” 38
CORRECT USE OF PPE IS IMPORTANT!!
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EBOLA DISEASE: END- POINT MESSAGE
Together as a team, let’s join to prevent Ebola from entering Cameroon.
2035: Emerging Cameroon = Emerging to break the cycle of disease & up-scaling health (Ebola, malaria, NTDs, non-communicable diseases etc).
Prevention is better than cure = correlates with Mission statement of GATH (Championing capacity building, advocacy, resource mobilization, trainings and multidisciplinary implementation research for a cohesive, inclusive, preventive, holistic and policy-driven health in disadvantaged and hard-to-reach grassroots communities for Universal health coverage)
(2018)Copyright ©Global Alliance for Tropical Health Motto: “One People, One Health”
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REFERENCES
U.S. Centers for Disease Control and Prevention (CDC, 2014). Interim Guidance for environmental infection control in hospitals for Ebola virus. WHO (2014). Ebola response roadmap update WHO (2015) Ebola Fact sheet Number 103 WHO (2015): One year into the Ebola epidemic: a deadly, tenacious and unforgiving virus. WHO Ebola Report. WHO/African Regional Office (2014). Standard operating procedures for controlling Ebola and Marburg virus Epidemics WHO (2014). INTERIM VERSION 1.1: Ebola and Marburg virus epidemics: preparedness, alert, control and evaluation WHO (2015): Ebola Road Map. Ebola Situation Report. www.cdc.gov/ebola
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THANKS FOR YOUR ATTENTION!!!!!
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